New CMS COVID-19 Reporting Requirement Includes Enforcement Actions

Thoughtware Article Published: May 20, 2020
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CMS published an interim final rule on May 8, 2020, requiring reporting of confirmed or suspected COVID-19 cases to the Centers for Disease Control and Prevention (CDC) through the National Health Safety Network (NHSN). This new reporting requirement is in addition to current reporting requirements for communicable disease and infections to state and local health departments.  

This national reporting requirement provides standardized information for various federal agencies to assist with national surveillance on the status of COVID-19 in all nursing homes. In addition, CMS intends to use this data to ensure providers are following the infection control requirements of participation, determine survey prioritization and assist with responding to the public health emergency (PHE).

All CMS Medicare and/or Medicaid certified long-term care providers are required to report the following data to the CDC in a standardized format:

  • Suspected and confirmed COVID-19 cases of staff and residents
  • COVID-19 deaths of residents and staff in any setting
  • Personal protective equipment and hand hygiene supply stock
  • Ventilator capacity and supply stock
  • Resident beds and census
  • COVID-19 testing access at the provider location
  • Staffing shortages

The new rule requires reporting these statistics at least one time per week. Providers may choose to report more frequently; however, the requirement is for weekly reporting. CMS prefers that providers consistently submit their statistics on the same day every week. The provider can choose the day of the week.  

In addition, the data reported must consistently occur over the same seven-day span. For example, report Monday through Sunday data every week.

Every Monday, CMS will monitor to determine compliance with the reporting requirements for the prior week. CMS will be monitoring timeliness and completeness of all required data by CCN number.

Public Reporting

CMS anticipates distributing the following reported data weekly to the general public via on Mondays by the end of May 2020:

  • Facility names
  • Number of suspected and confirmed cases
  • Number of deaths
  • Other data deemed appropriate

Enforcement Actions

During the PHE, current survey processes are focused on immediate jeopardy allegations and focused infection control. Enforcement actions related to reporting COVID-19 data include a deficiency citation and civil monetary penalty (CMP).

A new survey tag (F884) has been added specific to noncompliance of reporting the required COVID-19 statistics to the CDC. Federal surveyors (not state surveyors) will review reported data off site. Providers not submitting complete and timely data will receive a citation at F884 on CMS-2567 with an “F”-level scope and severity.  

The first set of COVID-19 statistical data was required to be reported by May 17, 2020, at 11:59 p.m. An initial grace period ending May 24, 2020, at 11:59 p.m., has been established prior to CMS action.  

Providers who fail to report after the third week by May 31, 2020, at 11:59 p.m., will receive a warning letter reminding the provider of the reporting requirement. Failure to report by June 7, 2020, at 11:59 p.m., will result in CMP. The first week of failure to report will result in a CMP of $1,000. Each additional week of noncompliance will increase the CMP by $500. The noncompliant weeks don’t need to be consecutive for CMP accrual.

For example:

  • First week of noncompliance: $1,000
  • Second week of noncompliance: an additional $1,500
  • Third week of noncompliance: an additional $2,000
  • Total for three weeks of noncompliance: $4,500

Providers who haven’t already done so should immediately register to report COVID-19 information to CDC’s NHSN Long-Term Care Facility COVID-19 Module. When reporting the required data, transmission can be verified immediately upon submission. Providers should have processes in place to verify compliance with complete, timely and accurate weekly submission to NHSN. 

As with most topics related to COVID-19, changes are being made rapidly. Please note that this information is current as of the date of publication. For the latest updates, visit BKD’s COVID-19 Resource Center. If you have questions, please reach out to your BKD Trusted Advisor or use the Contact Us form below. 

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